Running Head: HEALTH CARE POLICY

Health Care Policy Paper: Virginia House Bill 1757

Elizabeth Blanton

Bon Secours Memorial College of Nursing

Assistant Professor Catherine Mikelaites MSN, RN-BC, CMSRN

NUR 4240

March 9, 2017

Honor Code I pledge

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Health Care Policy Paper: Virginia House Bill 1757

School nurses make a difference in the lives of children on a daily basis. Unfortunately,

not all children have access to a school nurse. During the 2017 Virginia General Assembly, a law

was proposed to establish safe school nurse to student ratios and to establish one registered nurse

(RN) in every elementary school, middle school, and high school in the Commonwealth. There

are clear financial and health benefits to having a school nurse in every school, and these benefits

have been demonstrated in numerous published research studies. School nurses can improve

student health outcomes and reduce the burden of sick children on school employees and parents,

resulting in a benefit to the entire community. While the Bill in Virginia has been tabled, it has

started a conversation about student health, the increasing health needs of our Virginia students,

and how to allow access to education for all students, regardless of health status.

Health Care Law

During the 2017 Virginia General Assembly, Delegate L. Mark Dudenhefer (F) from

House District 2 and Delegate Kaye Kory (D) from House District 38 proposed Virginia House

Bill 1757 (HB1757). HB1757 proposes amending 22.1-253.13:2 and 22.1-274 of the Code of

Virginia, which relates to school staffing ratios for positions such as principals, assistant

principals, librarians, guidance counselors, teachers, operations staff, clerical staff, and nurses.

Section K of the Bill proposes that there be at least one RN for every 550 students and proposes

that every school board employ at least one full-time nurse in every elementary school, middle

school, and high school. In the original language of the Bill, the proposed ratio was one nurse

for every 1,000 students, but it was amended to one nurse per 550 students. On January 13,

2017, a House subcommittee recommended tabling the Bill, and it was left in the Appropriations

Committee as of February 8, 2017 (LegiScan, 2017).

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Impact on Nursing Profession and Patients

In the Commonwealth of Virginia, all public and private schools do not have an RN on

site at all times throughout the school day. In some counties and cities, one RN may cover

several schools, with a clinic aide attending to the basic health needs of students in the school

health clinic. In recent years, there has been a significant increase in student health needs. As

medical care has advanced, more students are able to return to school sooner after illness or

injury, or they are able to remain in the classroom despite health challenges at higher rates.

Examples of some of the chronic illnesses that have increased in students include asthma, type 1

diabetes, type 2 diabetes, and obesity. Childhood asthma rates have doubled since the 1980s

(Rodriguez et al, 2013), and from 1990-2008 the worldwide incidence of type 1 diabetes has

increased as well, including in the United States (Dabelea et al, 2014). Additionally, as the rate

of obesity has increased in youth since the 1960s, there has been a resulting increase in the

number of cases of type 2 diabetes, with 20% to 50% of new onset type 2 diabetes diagnoses

representing pediatric patients (Dabelea et al, 2014).

Public schools are required to provide education to all students, and as health needs have

increased for students, schools face a challenge in making schools accessible to all. There is a

clear and urgent need to ensure the safety of our Virginia students by establishing safe nurse to

student ratios and placing an RN in every Virginia school. In addition to the consideration of

student safety, when a school nurse is expected to care for more than 550 students at a minimum,

the nurse risks adversely affecting her nursing license by not being able to provide adequate and

safe care. HB1757 addressed this growing need in schools and proposed parameters for schools

to employ in order to keep students safe, while also creating a safe environment in which school

nurses can practice. It was unclear if both the American Association of Nurses (ANA) and the
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Virginia Association of School Nurses (VASN) supported HB1757; however, VASN has been

working to have similar language and ratios included in the Virginia Standards of Quality (VASN

Standards, 2017). The National Association of School Nurses (NASN) no longer provides

specific recommended nurse to student ratios, but prefers to look at the many different factors

influencing student care, such as the acuity of the overall student population and the students

social determinants of health, in order to provide safe care and a safe school nurse workload

(NASN: School nurse workload, 2015).

Financial Implications

HB1757 has financial implications to schools and community through cost-savings

associated with having a school nurse in each school, which is related to the increased costs

associated with sick students to school staff and parents. Several studies have examined the

financial benefits of having a school nurse in each school. Baisch, Lundeen, and Murphy noted

that administrators saw a decrease of 57 minutes in time spent managing student health related

issues per day; clerical staff saw a decrease of 46 minutes, and teachers saw a decrease of 20

minutes per day. This equated to an approximate savings of $133,000 per year for each school,

based on a breakdown of hourly wages (Baisch et al, 2011). An additional study focused on the

benefits of having a school nurse on students with asthma, and found that the presence of a

school nurse decreased ER visits and improved absenteeism rates. Based on data from the

Bureau of Labor Statistics and the California Department of Education, researchers determined

that the financial savings equated to approximately $75,700 per year with a full-time nurse

present (Rodriguez et al, 2013). Finally, a study published in JAMA in 2014 demonstrated that

for every dollar invested in school health services, society gained $2.20. The study found that by

spending $79.0 million dollars, the presence of a school nurse saved approximately $20.0 million
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in medical care costs, $28.1 million in parents productivity loss, and $129.1 million in teachers

productivity loss per year. This is a net benefit of $92.2 million dollars to society (Wang et al,

2014).

Opportunities and Challenges

The most significant challenge that the Bill faces is the financial cost. School budgets are

often very tight, and it is difficult to find and approve additional funding. Educators want to

spend the majority of their budgets on services that directly benefit students education. This

means that support services, such as nursing, may not be one of the top budget items. As

previously mentioned, studies have demonstrated that for every dollar invested in school health

clinic services, society gains $2.20 (Wang et al, 2014), yet the financial savings of having a nurse

may not be clearly and immediately visible, which hinders the approval of such spending.

Another challenge for this bill is that most schools already have a clinic aid. Not only do

advocates for this bill need to justify the cost of employing an RN, they must explain how an RN

is more qualified than a clinic aid to provide care to students in todays health environment.

Changing established practices, especially when such an improvement costs more money, is

often a challenge in any setting.

This Bill presents an opportunity for school nurses to advocate for their positions and

demonstrate to the community and lawmakers how beneficial their services can be. When

HB1757 was tabled, it demonstrated that there is a clear need to better educate lawmakers about

how essential it is to have an RN in every school and to limit school nurse to student ratios. One

way school nurses can effectively demonstrate their necessity and value in the school setting is

with data. NASN and the National Association of State School Nurse Consultants (NASSNC)

sponsor a program called Step Up and Be Counted! to collect standardized data from school
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nurses across the country. The program aims to collect data on a national level that accurately

reports a school nurses case load and does so in a uniform manner that allows data to be

compared accurately. School nurses can report information such as the number of children with

severe allergies, the number of doses of emergency epinephrine administered, or the number of

children with a specific chronic condition (NASN: Step Up and Be Counted!, 2017). This

program brings the direct efforts of school nurses to a national level, and data can then be used to

communicate with lawmakers about student health needs in our country.

As the legislature establishes laws that directly affect nurses, it is important for nurses to

be advocates for their profession and for themselves. School nurse to student ratios keep

students safe and create a safe environment in which nurses can practice. Without direct input

from nurses, lawmakers cannot understand the needs of students, patients, and nurses. HB1757

was a good attempt at improving the healthcare within the school system, but fell short when it

did not have enough support to become a law. Lawmakers were not able to understand the full

benefit of having a school nurse in every school, which includes financial benefits to schools and

the community, improved health outcomes for students, and an improvement in the learning

environment. Overcoming the financial obstacle of establishing safe school nurse to student

ratios will ultimately create an opportunity to improve student education and health.

References

Baisch, M. Lundeen, S., & Murphy, M. (2011). Evidence-based research on the value of school
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nurses in an urban school system. The Journal of School Health, 81(2), 74-80.

Dabelea, D., Mayer-Davis, E., Sydah, S., Imperatore, G., Linder, B., Divers, J., Bell, R., Badaru,

A., Talton, J., Crume, T., Liese, A., Merchant, A., Lawrence, T., Reynolds, K., Dolan, L.,

Liu, L., Hamman, R. Prevalence of Type 1 and Type 2 Diabetes Among Children and

Adolescents From 2001 to 2009. (2014). JAMA, 311(17), 1778-1786.

LegiScan. (February 8, 2017). VA HB1757- 2017- Regular Session. Retrieved on February 28,

2017 from https://legiscan.com/VA/bill/HB1757/2017

National Association of School Nurses. (2015, January). School nurse workload: Staffing for

safe care. Retrieved on February 22, 2017 from

https://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStateme

ntsFullView/tabid/462/smid/824/ArticleID/803/Default.aspx

National Association of School Nurses. (n.d.) Step up and be counted! Retrieved on March 2,

2017 from https://www.nasn.org/Research/StepUpBeCounted

Rodriguez, E., Rivera, D. A., Perlroth, D., Becker, E., Wang, N. E., & Landau, M. (2013). School

Nurses Role in Asthma Management, School Absenteeism, and Cost Savings: A

Demonstration Project. Journal of School Health, 83(12), 842-850.

Virginia Association of School Nurses. (n.d.). VASN standards of quality position statement.

Retrieved on February 22, 2017 from http://www.vasn.us/news.html

Wang, L. Y., Vernon-Smiley, M., Gapinski, M.A., Desisto, M., Maughan, E. & Sheetz, A. (2014).

Cost-benefit study of school nursing services. JAMA Pediatrics, 168(7), 642-648.